Stones and Knives

No chemist I, unable to explain solubility constants or crystal formation, I can only note and admire: gallstones come in all sizes, shapes, and textures. Hard and shiny like agates, faceted like emeralds, crumbly like clay. Mulberry-shaped, round, uniform or uneven; surfaces determined by their neighbor, or identically shaped as if manufactured. Green, black, bright yellow, fecaloid. They can occur by the hundreds in a single gallbladder, or fill up an entire bag in the form of one gigantic rock. Feeling like a magician, I liked to save a few from the lab and present them to their owners, more amazed than if I'd pulled a quarter from behind their ear. I always enjoyed looking at gallstones. Unless they were oozing out of a gooey gallbladder in the middle of an operation, like cockroaches from a garbage bin.

Learning surgical technique is an incremental process. The student may be allowed to cut some sutures, maybe even tie a few. Simple as that is, it allows a sense of tissue tension, unlearns the old way of holding scissors, teaches the new. Taking up a knife and cutting through the skin requires overcoming practically everything you ever knew. I was eventually allowed to "do" a hernia as a student (a rarity indeed), although I really had no idea what was happening, anatomically speaking. The resident held something in such a way that I had no question of what I was to do, and I did it. As an intern, I did more of them, getting better at maneuvering instruments, placing sutures where I aimed them, cutting without shaking so hard it was visible across the room. Taking out a gallbladder was, where I trained, too big a deal for an intern. It was real surgery, inside the abdomen, close enough to structures of significance, demanding enough of dissecting skills that we waited a year before getting the chance. So it always held special significance: like passing through a portal, like being taught the secret handshake. Tourists in fancy eateries are shown to the main dining area; locals get invited to the wood-paneled special rooms upstairs.

You can do some operations without knowing how to operate. In my book I wrote "with enough bananas, you could teach a monkey to take out an ovary." Some gallbladders are so easy to remove, hanging loosely under the liver like a pluckable plum, that I refer to them as "gynecologic gallbladders." If your first couple of gallbladders are like that, you can get lulled into thinking you know what you're doing. (Way back in my early practice days, when our community allowed more or less unfettered surgery privileges, more than once I was urgently invited in to bail out a family doc who discovered dramatically the mysteries held in the right upper quadrant, and who'd been epiphanized into the realization that knowing how to hold a scissors in one's hand does not a surgeon make.) In those same ancient times, it was believed that operating when the gallbladder was actively inflamed was to be avoided at almost all costs. Whereas it's true that most attacks of acute cholecystitis simmer down without the need for emergency intervention, they don't always. Gallbladders can get severely infected and can rupture (especially in diabetics); acute attacks can flare up again during a cooling off period. More recent studies tend to show that early intervention isn't associated with more problems than waiting. But it sure as hell requires knowing how to operate.

While serving in Vietnam, I "flew" EC-47s. The pilot would arrange power settings and trim, giving over to me the stick and rudder. I "did" takeoffs and landings, accomplished some cool maneuvers over the China Sea. Shit hot, as we pilots liked to say. On final approach, if the crosswinds were a little too harsh and I was coming in crabwise, at the last minute he'd say "I got it" and keep us alive. Under tight tutelage I removed a few gallbladders early in training, and came to feel I could do it. When I first encountered the real thing while helping a young 'un -- a red, swollen, pus-filled gallbladder, speckled with the black spots of gangrene and stuck tightly to the colon and liver -- I squealed for help like a kid who'd wandered out of the shallow end. Throughout my career, when I'd be working my way through such a mess with confidence, at some point I'd always remind myself of that first really scary one, and allow myself a smile. Behind the mask.


In the illustration above, you can see how the colon makes a sharp left turn (the "hepatic flexure" -- "left," by the way, orients vis a vis the patient). In life, it's immediately below the gallbladder, very often touching it. Same with the duodenum, which isn't marked but is the C-shaped tube at the bottom of the stomach. Uninflamed, those structures easily peel away from the gallbladder. There's a thin covering of the gallbladder which holds it to the undersurface of the liver, filmy, as if it were sprayed on, easy to navigate, buzzing a few small bleeders on the way. Down at the business end, the tube that connects the gallbladder to the main bile duct, and the artery that feeds the gallbladder (cystic duct and cystic artery) are usually not to hard to identify and divide: in most cases it takes a little dissection through a layer of fat to find them, typically not a great challenge. Ironically, though, some studies show that it's when things are "easy" that injury is most likely to occur: when your guard is down, you feel relaxed and floaty, recreational, and you might not attend as intently to the anatomy. So they say. Subtle anatomic variations occur here, and they can fool you. Still, with care, it's fun and safe.

Oh man! Not when the gallbladder is acutely inflamed or infected or both. That sprayed-on film is now thick as a the peel of a grapefruit. The colon -- duodenum, also, maybe -- is plastered to the mess and has become inflamed, too, such that where one ends and the other begins is anyone's guess. The adjacent surface of the liver, caught up in the raging redness, is gooified and extra bloody. And the little duct and artery? Good luck! Encased in dense edematous tissue and often indecipherable. This is where everything you've ever learned about handling tissues, every trick you were taught and every wrinkle you've come up with yourself needs to come front and center. When nothing is normal, no move has a predictable outcome.

How can I describe a combination of caution and boldness, of confidence and trepidation? What does it take to enter such a zone recognizing the danger but believing you can do it? (Not as much as entering a burning building or a free-fire zone.) In "Cutting Remarks," I came up with the term "delicate brutality." I like it (in fact, I've since thought that would have been a better title for the book.) You can't blunder into the foray swinging sledgehammers like an orthopedist. But if you diddle around forever, nibbling at the edges, afraid of the water, you'll drag the operation out too long: the sicker you are, the less you need a long anesthetic. So you resort to techniques that can move along briskly but respectfully. Blunt baby steps. A careful cudgel. Delicate brutality.

Slippery Stones: more about the gallbladder

"If you don't have a pretty good idea what's going on with your patient after a thorough history and physical," I was told in medical school, "you probably never will." It's a wise -- if a little dated -- statement. Most of the time, diagnosis isn't all that hard. Rare things are rare. Common things are common: another med-school pearl of wisdom. Figuring out the problem in those outlier situations can be frustrating on each side of the white coat and, in the case of surgery, can lead to errors in both directions: doing operations that don't help, or deferring ones that otherwise might. The gallbladder has been the source of more than its share of such scenarii.

Delicate and robin's-egg blue, the normal gallbladder is startlingly beautiful. Out of place among the muted earthiness of the rest of the abdominal anatomy, it peeks above the lower edge of the right lobe of the liver, demure, nearly luminous; typically you see only the top of it, the rest hidden by the colon and omentum. It's as if the body is shy about revealing such surprising and incongruous loveliness. Aiming to remove it, seeing that color signals a likely easy time; hoping to help a person with grey symptoms, finding a blue bag makes you wonder what you're doing. With significant chronic gallbladder disease, the organ generally is thick and reddened, although in between attacks it can resume its avian amiability.

"Well, doc, whenever I eat freedom fries, few minutes later I get this horrible pain right here [pointing just below the right rib cage]. Goes right through me into my shoulder blade. Hurts like hell. I get to writhing around, puking my guts out, can't stand up, can't sit down. After twenty minutes it starts to go away, and I'll feel fine again. Oh, and my doc asked me to bring you these [shows me ultrasound images of his gallbladder, full of stones.]" No brainer. Textbook stuff. That man is going to love me for liberating him from the clutches of his gallbladder. The preceding, by the way, is a classic description of "biliary colic," resulting from a stone plugging up the outlet of the gallbladder when it's trying to empty itself of bile. It differs from "acute cholecystitis," which is a more severe situation, resulting from the stone lodging in the outlet and not letting go. Instead of just hurting like hell for a few minutes, the gallbladder gets inflamed, swollen, sometimes infected. It's potentially more dangerous than colic. The distinction, I'd have to say, is often lost on non-surgical medical doctors. But I digress.

"Well, doc, whenever I eat french fries..... [repeats the above story including handing me the ultrasound, which is entirely normal.] That's a diagnostic problem. Or this: "I get heartburn a lot. Sometimes I'm nauseated for no reason. [Shows me repeat of the first ultrasound, stones aplenty.] I've heard variations on those themes countless times, and it's a dilemma. Many tests follow, but explanations remain elusive. Operations may or may not ensue. The sad saga of one of my patients is illuminating. Since it's complicated, maybe I'll just tell the story straight through, and consider the implications later.

I'd operated on her for another reason in the past. Now under the care of docs at a hoidy-toidy medical center, she came back to me when surgery was recommended. She'd been through an extensive workup for abdominal pain, not typical of gallbladder origin, but conceivably so; her gallbladder was, by all measures, normal. At the mecca of medical mastery she'd undergone a test on the basis of which it was decided she had problems with the valve at the end of the bile duct (sphincter of Oddi dysfunction -- more about that little gem, later) and she'd been advised to have her gallbladder removed. I called her gastroenterologist: why, I asked him, had he not cut the valve (the usual treatment) when he was there with his scope? Wasn't taking out her gallbladder attending to the wrong end of the stick? Removal of the gallbladder, he said, was curative sometimes (for unknown reasons); and it was their protocol not to cut the valve (papillotomy) in people who hadn't had cholecystectomy (official and impressive term for gallbladder removal). OK, I said. You're the professor.

The operation went fine. (I've always said unnecessary surgery gets a bad rap: it's easy, and people recover faster than when they're actually sick.) Her pain persisted. From her Meccanized professor, she then got her papillotomy, after which she in fact felt better for a while. When her symptoms recurred, a scope showed the sphincter had scarred down, so it was re-cut, after which she was better again, but for a shorter time, after which it was again scarred small. At that point her gastroenterologist recommended surgically cutting the sphincter; that made sense to me, because it seemed the "medical" cutting had helped, and I knew the surgical approach was more definitive and permanent, if a bigger deal. So I did it, a major procedure involving opening the duodenum and carefully (so you don't cause a leak) slicing the end of the bile duct and tacking it open with sutures. Once again she seemed to have been improved, for a while. When her pain returned, her umpteenth scope Xray showed my operation to be wide open, but her doc had her see Supersurgeon at the mecca. He recommended going back in and cutting her pancreatic duct where it joined the bile duct, figuring that in some way I'd compromised its drainage with my operation. I hadn't. (Below is a diagram that shows the relationships. Ignore the stone, in this case.)



Had I somehow interfered with drainage from the pancreas, and were that a cause of her problem (which didn't make sense, since her symptoms were the same as those before any of these procedures were done), that duct would be seen to be dilated on Xrays. It wasn't. My patient wanted me to do the operation if it was do be done, but that's where I drew the line: for one thing, it made no anatomic sense to me in her situation, and for another, I'd never done it -- at least not that way. I told her both reasons. So Supersurgeon did it, finding no operative evidence of a problem, but soldiering on.

When there was no improvement at all, so my patient later told me, and when she had another scope-Xray to check it out, the surgeon entered the exam room, walked past her to the Xray, looked it over, said "Well, my operation isn't the problem," turned on the heel of his bootie-covered shoe, and walked out without ever having said hello.

I tried everything remaining: wound injections and scanning for hernias, pain clinic referral, obtaining opinions from all sorts. The best I could do, at some point, was to assure her that whatever else was true, it was possible to be sure there was nothing going on that was dangerous to her. She continued to visit the clinic, and finally found some sort of equilibrium with her pain. In my next post, I'll try to deal with some of the issues raised. (The assholery of the surgeon will have to stand on its own, addressed no further...)

Rocks in a Bag: what I know about gallbladders

Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it's the thing upon which I operated most (if you don't count breast biopsies). And I liked it. When a person came to see me with a clear-cut gallbladder problem -- which was the case at least 90% of the time -- I could be quite confident that I was going to make him or her happy and, most likely, have a little fun while doing it. But there's the rub: it's not always a Tenantoid "slam dunk," nor is it always fun. A mysterious little bugger is that bag of bile: perhaps more than any other organ it's able to elude or confound diagnosis despite such apparent simplicity. And more than any other category, I sent people home from my office without surgery despite being referred with the idea of separating them from their gallbladders. Rocks get in your head.

First, some basics.

Among the many functions your liver performs for you (in addition to feeling neat) is the manufacture of bile, which is a clarified-butter-yellow liquid of complex composition and which serves to help with the absorption of fatty substances into your bloodstream. (The ancients believed it had something to do with emotions: "melancholia" means, literally, "black bile.") About a quart of bile per day is produced and flows from the liver through a tube called the bile duct, entering the duodenum just below the stomach. Of that quart, a few tablespoons are sidetracked into a pouch that hangs under the liver, and is called the gallbladder. It doesn't make bile; it stores a bit of it, with the intention of squirting a dose into the intestine once in a while, particularly after eating a fatty meal. (The picture to the left, by the way, is not to scale. It makes the gallbladder look much huger than it usually is.) There's some complicated anatomy involved, particularly since the south end of the bile duct passes through the pancreas, where it's joined by a duct therefrom, carrying digestive enzymes made therein. We'll get around to the implications thereof, later.

Here's my theory: the gallbladder evolved before refrigerators, when people might starve for a day or two or three while they hunted their next meal. After a kill, they'd gorge on a big greasy meal, at which point a supplemental blast of bile was useful. (During starvation, the gallbladder can get impressively large and full of bile.) Compared to those days, we eat more or less constantly: two, three, four meals a day, a few snacks. Bile remains a necessary component of digestion, but storage isn't really called for. Our food sort of steadily drips into the intestine, so constantly dripping bile works fine. Which is why the vast majority of people who have their gallbladder removed never miss it at all.

Bile is composed of many chemicals which are supposed to remain dissolved in the liquid medium. In some people, for various reasons (genetic, diet, certain prior operations, certain blood diseases, etc) one or another of the components of bile are in too high a concentration to remain dissolved, and they precipitate out, forming crystals, which tend to grow larger and larger -- like sugar candy on a string. Stones. Trouble.

Well, not always. Some people have gallstones all their lives and never hear from them. It's muscular contraction of the gallbladder that sends the bile into the bile duct. If a stone happens to be near the opening of the gallbladder when it squeezes, it clamps down and cramps up on the stone, gets plugged up, and that hurts or causes other problems. If the stones are out of the way during the squeeze, there may be no symptoms at all. Which means not everyone with gallstones needs surgery, a decision made easier with the use of a crystal ball. I'll see if I can do justice to that, and other concepts, in the next few posts...

[UPDATE: many readers who find this post by a web-search may be unaware it's the first in a series. The others are here, here, here, and here.  Answers to remaining questions might turn up within them. Please check them out.]

Mini Me

"Big surgeons make big incisions," said the visiting professor at our Saturday morning conference on deaths and complications. He could also have chosen to say "incisions heal side-to-side, not end-to-end," which was another aphorism professors liked to repeat, with the same implication: for safety's sake, the bigger the incision the better. In a training program -- especially in the ancient times in which I trained -- the point was made often. When open incisions were the only game in town, and when a young surgeon-in-training found him- or herself in difficulty, the first thing the attending was likely to do was to enlarge the cut. And, as I said in a post a while back, there's nothing quite like stepping up to the table and making a bold and generous incision; especially when carrying it through skin and fat and fascia in one glorious and heraldic (if medieval) stroke. By contrast, poking little holes in a belly for inserting scopes is like peeing sitting down.

So I grew up making big incisions, with no second thoughts. Until I thought third: you can indeed make them larger, so why not start small and -- assuming the ability to anticipate before causing a problem -- enlarge if necessary. Bigger wounds hurt more, and are more traumatic, requiring more energy to heal. More pain, more tiredness, slower recovery. Made sense to me. So I changed direction. Rather than go to extremes and start tiny, I simply began to make incisions for all the operations I was doing smaller and smaller over time, heading to an unknown end-point. And that's how I invented mini-cholecystectomy (cholecystectomy = gallbladder removal.)

Well, I suppose I can't claim I invented it. Like several good ideas I've had over the years (another post?), I've come up with a few things up with which others seem to have come as well. My kind of good ideas, evidently, aren't the kind to stop the world from turning: if I think of them, so do others. But there are a few things -- taking gallbladders out through tiny incisions among them -- that I just started doing before there were professors publishing articles about them. (You can read more about these things here.) In the case of "mini-cholecystectomy," it evolved in my practice simply by steadily decreasing the size of the cut from an initial eight inches or so, to six, to four, to three, to two and, eventually to one or one-and-a-half. Somewhere along the line, I had significantly to change techniques: for one thing, no OR light shines through my head into such a hole, so I started wearing a surgical headlight. For another, I ordered some very narrow bendable retractors, figured out different ways of inserting packs, used different methods of teasing the gallbladder away from the tissues that sometimes surround it. I figured out how to "walk" my way down the gallbladder with long instruments, exposing the important anatomy at its bottom end using a thin suction catheter. The patients recovered very rapidly: instead of the typical three to five day stay (when I trained, it was closer to a week), I was sending patients home happy in a day or two. Then one. Eventually (I admit it was only after the laparoscopists came along -- which happened a while after I'd perfected my version) nearly all of my patients went home the same day, and ultimately I did most of my gallbladder surgery at a free-standing surgery center.

I thought more than once that I should write it up. What kept me from doing so, mainly, was the realization that I'd evolved the technique gradually, going from a very wide view to a harrowingly narrow one over enough time to be confident in what I was doing. If someone tried it straight off, I feared, they'd booger the bile duct, lacerate the liver and generally trash the technique. Whatever else is true about it, it ain't exactly easy, especially when it's hard.

After a few years, papers began appearing, especially in England. Some even called it "mini-cholecystectomy," which is the term I'd begun using in my operative reports, having never heard it elsewhere. Since laparoscopic gallbladder removal had pretty much taken over the world, and since I steadfastly resisted it (I took the courses, I could do it easily and enjoyed it), I was pleased that these reports confirmed what I'd been saying to colleagues: mini was way cheaper than laparoscopy, and was otherwise the same in terms of patient discomfort and recovery. And mind you: these reports were defining "mini" as an incision less than eight centimeters. That's more than three inches!! With incisions half that size, my patients had less total incision than the lap patients with their four holes, and less pain. Still, I feared writing it up. (Interesting note: in at least one study comparing lap- and mini-chole, the patients were randomized after going to sleep, into one group or the other. Everyone received a bandage large enough to cover either a mini hole or the spread-out four holes, so neither the patient nor the nurses taking care of them knew from looking which they'd had. Same results in each, except for lower mini costs. Cool study! This was when patients were staying in the hospital, and had they had "my" operation, I'm guessing they'd have gone home sooner than the laps.)

At one point, I entertained the idea of hooking up a video camera to my headlight and recording the procedure, developing some sort of presentation to teach it. Hell, charge for seminars!! But I didn't. I did have some pictures taken, at the request of a couple of OR nurses, having been invited to give a talk about the procedure to a regional meeting of AORN, the association of operating room nurses. Had nice slides, the last one of which showed, for all to see, the incision covered by two half-inch steri-strips. They were impressed. The slides that got the most murmurs, however, were the ones that compared the nursing set-up: for the lap-chole, a table covered with tubes, trocars, all sorts of very expensive instruments. For mine, a couple of long clamps, two three-quarter inch retractors, a few of the usual surgical instruments used since the Red Sea parted, and a clip applier.

Is laparoscopy a step forward? Absolutely! For many operations, it's an unmitigated marvel. And the technology has advanced at light-speed. Is it over-hyped? Yep, in my opinion. When you can take out a gallbladder through a one-inch incision in twenty minutes or less, as an outpatient; when you can resect a colon through a three-inch incision in forty-five minutes or less and have the patients go home in two days, I can't think of a reason to do it laparoscopically for thousands of dollars more/pop. Clearly, however, I lost that battle a long time ago: there's billions of bucks behind the hype. The public thinks it's the only way, and surgeons would rather learn the cool stuff. Despite the opportunity to save a gazillion dollars a year, the chances of my approach taking hold are ze-fricking-ro. I'll say this, though: in my little corner of the world, as time went on I had patients coming to me because they'd heard what I was doing and preferred one small hole.